Healthcare Provider Details

I. General information

NPI: 1487352704
Provider Name (Legal Business Name): JALEESA WRENCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVER PLACE DR STE 250
DETROIT MI
48207-5402
US

IV. Provider business mailing address

100 RIVER PLACE DR STE 250
DETROIT MI
48207-5402
US

V. Phone/Fax

Practice location:
  • Phone: 313-871-2237
  • Fax:
Mailing address:
  • Phone: 313-871-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6851115619
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: